Paying the Bills

For many of us, the system for financing health care in the United States is not working. Health care costs are rising, benefits through our health insurance plans are shrinking, and a significant percentage of the population, perhaps as many as 37 million Americans, have no health insurance coverage at all. An additional 50 million Americans who may be lucky enough to have some health insurance find their coverage inadequate -- unable to meet their families' needs.

A person who has a genetic disorder stands a strong chance of being rejected for health insurance because his or her potential health care needs may make coverage unprofitable to an insurance company. Even in those instances where an individual has only a genetic predisposition to a disorder or has a disorder which is not disabling and does not require medical treatment, many companies turn down health insurance applications. If a policy is obtained, the person may discover that it doesn't cover any medical disorder already present before the purchase of the policy. Such medical disorders are known as preexisting conditions.

If a preexisting condition is not disclosed when asked on an application for coverage, the insurance company has the right to invalidate the policy when a claim is made. In most cases, the claimant's premium dollars will be refunded and the coverage stopped.

Most large group plans go into effect after employees have been at work for a specified length of time (usually six months) and they may not have limitations on preexisting conditions.

For family planning purposes, prenatal testing which has shown that a child will be born with a genetic disorder causes that disorder to be classified as a preexisting condition. That preexisting condition must be disclosed for health insurance purposes. Additionally, many policies consider pregnancy itself a preexisting condition when it has occurred before the policy was obtained. Thus, if you are considering having children, it might be wise to obtain health insurance or change insurance before becoming pregnant or at least before undergoing prenatal testing. Some insurance policies do not cover maternity services at all.

If you have insurance, it is probably wise to try to retain your present policy, or at least to keep it until you have had a chance to examine other possibilities thoroughly.

Before changing jobs, investigate thoroughly the coverage and preexisting conditions clause of the policies which your new employer offers.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) requires the employers of twenty or more employees to offer continuation of health care coverage for 18 months to terminated employees. People who are eligible for SSI Disability whether income eligible or not may receive COBRA coverage for as long as 29 months and some qualified dependents may be eligible for 36 months. Under this law, the person who is insured must pay the full insurance premium out of his own pocket. It is possible to convert a group plan to a less comprehensive individual policy if COBRA coverage runs out before you have found a new job. Just don't let your coverage lapse.

When a dependent child reaches the age of majority, a new insurance crisis may arise because he or she may no longer be covered by the parents' policy. Some policies permit you to convert coverage to an individual policy when a dependent child reaches the age of majority. The important thing is not to let your child's health insurance coverage lapse before obtaining new insurance in his or her own name. Be sure to begin the process of seeking new coverage for this child at least three months before the time the policy would expire.

For a more in-depth treatment of this subject, you will want to obtain one or more of the following, or ask your local library to obtain them for their collection.

Health Insurance Resource Guide. $10. Prepared by the Alliance of Genetic Support Groups, 35 Wisconsin Circle, Suite 440, Chevy Chase, MD 20815. 1-800-336-GENE. Explains the different kinds of health care coverage available in the United States, and how the rules work. Also provides information on options available when insurance is denied.  

Fighting Back Health Insurance Denials, by Robert Peterson, J.D., with David Tenenbaum, M.A.. $14.95. Published by the Center for Public Representation, Inc., 121 South Pinckney Street, Madison, WI 53703. Phone 1-800-369-0338.

Introduction to the world of health insurance, with tips for getting the best type of coverage and strategies for combatting claim denials. The book outlines the most common reasons claims are denied, arguments and evidence people can present to insurance companies, and what to do when all else fails.  See Out of print.  See alternatives in the Bookstore.

Paying the Bills: Tips for Financing Health Care for Children with Special Needs. $5. Prepared by New England SERVE under a grant from the Maternal and Child Health Bureau. New England SERVE, 101 Tremont Street, Suite 812, Boston, MA 02108. Phone 617-574-9493 A 56-page booklet with a good overview of the topic, and an excellent bibliography. Good information for everyone, not only for the needs of children.  Out of print.  See alternatives in the Bookstore.